GT 68 year old Male Admitted 10/2 HO HTN, DM, TIA, anemia presented with weakness and difficulty walking No
allergies. Weight on admission 191, now 173.
Symptoms started 10/2 after being discharged from rehab.
Initial Labs: H/H 7.7/23, PLT 454, BUN/Cr 44/3.59, Albumin 2.9, ALK Phosphate 348, ALT 105, AST 78BNP 4184! Should
be less than 100, Tropinin I 0.03/0.04, Glucose 159 CXR Nonspecific bilateral interstitial infiltrates (pulmonary edema)
Problem list #1 Acute anemia, #2 DM, #3ARF, #4 CKD, #5 Metabolic Encephalopathy
Last Notes 10/11/21
Acute Renal Failure syndrome Foley Catheter, Hyponatremia sodium to correct
10/10/21 Assessment & Plan Acute or chronic diastolic HF 68 yr old male, HO CHF, HTN, CHB, s/p PPM Medtronic 2/21
admitted with anemia Pt with AKI on CKD with improved creatinine, also uncontrolled HTN. IVF for increased
creatinine. Likely from overdiuresis/urinary retention. High creatinine Foley put in 10/9. Recommendation keep it in
due to retention
Echocard 2D on 10/3/21 Results: Mild concentric left ventricular hypertrophy.
Ejection Fraction=50-55% Diastolic dysfunction Grade II. Mild to moderate mitral regurgitation by color flow Doppler.
Severe pulmonary hypertension. No pericardial Effusion. Pacemaker lead in right ventricle. Moderate tricuspid
regurgitation. Pulmonic Valve: mild to moderate pulmonic valvular stenosis.
Radiation History
10/2 CXR showed enlarged heart & left pacemaker in place 2/21 Medtronic
10/4 Ultrasound Abdomen General, Kidney HO Hepatitis, Renal Failure Finding: ‘evaluation mildly ltd by pt condition’
Liver is mildly enlarged. Normal echogenicity. Main portal vein is patent with hepatopedal flow. Gallbladder is
thickened. Wall thickness 6 mm, 8mm filling defect in the gallbladder concerning for polyp. Small nonmobile echogenic
foci in the neck compatible with calculi. No pericholecytic fluid. No Murphy sign detected. Kidneys are normal. No
atrophy or hydronephrosis. Spleen normal. Impression notes: ‘if there is concern for acute cholecytitis consider HIDA
scan. Mild hepatomegaly. No bile duct dilation. Normal kidneys
10/4 Hepatobillary for right upper quadrant pain. Impression: normal exam, no scintigraphic evidence for acute
cholecystitis.
10/4 NM Choletec Nuclear Medicine Hepatobiliary Scan Impression: Normal no evidence for acute cholecystitis.
10/8 Urinary Bladder Ultrasound History or Urinary Retention Findings: Urinary bladder exhibits diffuse wall thickening
and trabeculation consistent with the sequel of chronic bladder outflow tract obstruction. Prostate is not enlarged, but
is nodular and indents the base of the bladder indicative of BPH (age related prostate gland enlargement that can cause
urination difficulty).
10/11 scheduled for Nuclear GI Bleed Imaging
10/11 scheduled for TC99M tagged RBC w/ultratag
Glucose continues to be high read 185, normal is 70-99
1
Had a blood transfusion on 10/11/21
ADMITTING DIAGNOSIS LETHARGIC/WEAKNESS
One of notes 10/7/21 Assessment & Plan state: Chronic kidney disease stage 4 Cr rose slightly likely from Lasix hold
dose…already received one already that day.
COMPREHENSIVE METABOLIC PANEL 10/11/21
GLUCOSE
78
(70-99) mg/dL
SODIUM
135
(135-145)
mEq/L
POTASSIUM
4.4
(3.5-5.2)
mEq/L
CHLORIDE
98
(98-108)
mEq/L
CO2
25
(22-30) mEq/L
ANION GAP
16
(8-16) mEq/L
CALCIUM
8.5
(8.4-10.3)
mg/dL
H
(8-26) mg/dL
BLOOD UREA NITROGEN
66
Indicates kidneys are not working properly
CREATININE
H
4.37
eGFR AFRICAN AMERICAN
(0.72-1.25)
mg/dL
L
16
(>60)
mL/min/{1.73_m
L
14
(>60)
eGFR NON-AFRICAN AMERICAN
measures kidney function
mL/min/{1.73_m
Glomular Filtration Rate shows how well the kidneys are filtering. # should be above 60
PROTEIN, TOTAL
ALBUMIN
L
6.3
(6.1-7.9)
2.6
(3.5-5.0)
g/dL
3.7
(2.0-4.0)
g/dL
0.7
(1.7-2.2)
ALK PHOSPHATASE
H
260
ALT
47
(6-55) IU/L
40
(5-34) IU/L
GLOBULIN
A/G RATIO
AST
H
L
BILIRUBIN, TOTAL
0.45
g/dL
(40-150)
IU/L
(0.2-1.2)
mg/dL
2
WBC COUNT
8.9
7.6
7.3
8.1
7.8
HEMOGLOBIN
L 8.4
L 8.5
L 8.3
L 8.2
L 7.3
HEMATOCRIT
L 26
L 26
L 25
L 25
L 22
427
426
445
398
PLATELET COUNT
417
SODIUM
136
L 132
L 131
L 130
L 133
L 133
135
POTASSIUM
4.2
3.9
4.3
4.6
4.7
4.7
4.4
CHLORIDE
101
L 96
L 96
L 95
L 95
L 97
98
CO2
L 21
L 19
L 20
22
24
23
25
BUN
H 56
H 59
H 60
H 63
H 66
H 71
H 66
CREATININE
H 4.09 H 4.34 H 4.40 H 4.44 H 4.59 H 4.57 H 4.37
GLUCOSE
93
71
74
H 111 H 232 H 181 78
CALCIUM
8.8
8.9
8.7
8.5
8.8
L 8.2
8.5
10MG AMLODIPINE OD
40MG ATORVASTATIN OD6
5MG
FINASTERIDE
5000UN
OD
HEPARIN SODIUM 5000 UNIT/ML
Q12
100MG HYDRALAZINE Q8H
SScale INSULIN - LISPRO 100 UNIT/ML ACH
25MG QUETIAPINE
1TAB
HS
RENAL MULTIVITAMIN (b complex-c-folic acid)
100MG SERTRALIN OD
125MG SODIUM FERRIC GLUCONATE 12.5MG/ML
OD
0.4MG TAMSULOSIN
OD
IV Fluids 75mL/HR
SODIUM BICARBONATE 1 MEQ/ML 8.4%
PRN Medications 650MG
ACETAMINOPHEN
PRN
IV
Q4H
3
10/09/21 COMP
SPECIMEN COLLECTION 10/09/21 6:50 1 NORTH
COMPREHENSIVE METABOLIC PANEL
GLUCOSE 74 (70-99) mg/dL
SODIUM L 131 (135-145) mEq/L
POTASSIUM 4.3 (3.5-5.2) mEq/L
CHLORIDE L 96 (98-108) mEq/L
CO2 L 20 (22-30) mEq/L
ANION GAP H 19 (8-16) mEq/L
CALCIUM 8.7 (8.4-10.3) mg/dL
BLOOD UREA NITROGEN H 60 (8-26) mg/dL
CREATININE H 4.40 (0.72-1.25) mg/dL
eGFR AFRICAN AMERICAN L 16 (>60) mL/min/{1.73_m2}
eGFR NON-AFRICAN AMERICANL_13 (>60) mL/min/{1.73_m2}
GFR <60 mL/min/1.73 m2 may indicate chronic
kidney disease. Estimated GFR
reflects the MDRD equation and may not be
appropriate for all patients or dose
calculations of toxic drugs excreted by the
kidneys. A GFR measurement using
clearance methods may be indicated.
PROTEIN, TOTAL 6.7 (6.1-7.9) g/dL
ALBUMIN L 2.7 (3.5-5.0) g/dL
GLOBULIN 4.0 (2.0-4.0) g/dL
A/G RATIO L 0.7 (1.7-2.2)
ALK PHOSPHATASE H 300 (40-150) IU/L
ALT H 57 (6-55) IU/L
4
AST 32 (5-34) IU/L
BILIRUBIN, TOTAL 0.37 (0.2-1.2) mg/dL
5